Healthcare Provider Details

I. General information

NPI: 1124439757
Provider Name (Legal Business Name): MICHAEL COSULICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 HIGHWAY 138 WEST BUILDING 2, SUITE 122
WALL NJ
07719
US

IV. Provider business mailing address

3350 HIGHWAY 138 WEST BUILDING 2, SUITE 122
WALL NJ
07719
US

V. Phone/Fax

Practice location:
  • Phone: 732-280-1200
  • Fax: 732-280-1207
Mailing address:
  • Phone: 732-280-1200
  • Fax: 732-280-1207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number24922
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA09959400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: